Women often send us material they find on the net they feel is important to share. We appreciate this immensely and this page is dedicated to these essays, articles, etc. If you would like to contribute please contact us. We have included references where possible. More bulletins are listed on the sub pages listed on the toolbar to the left.

__________________________________

Birth Trauma Can Cause Women to Develop PPD & PTSDA Discussion About Birth Rape and Its ResultsWe all know that birth trauma can occur in infants, but what about women? For years women have been suffering in silence from birth trauma that results from their treatment during labor and delivery of their child. The feelings some women have about their negative experiences are overwhelming, so much so that some women suffer from PTSD afterwards. Some women refer to their treatment as birth rape, especially if they had instruments placed inside them without their consent.

Some believe people use the term 'birth rape' to sensationalize their trauma and feel it is disrespectful to actual rape victims. The pain these women feel is just as real, and they are just as much victims as anyone else. One dictionary definition of the word rape is "to violate or abuse." State laws about rape usually consider any forceful penetration of the vagina or rectum to be rape. Ladies suffering from birth trauma display some of the classic symptoms of rape victims, including silence and shame about their ordeal.

This can include having Q-tips, speculums, scissors, forceps, vacuums, fingers, hands, and other objects inserted into a woman's vagina or being given an enema, IV, epidural, or C-section without her consent. Having one's water broken is another example of doctor's taking control, which is basically what rape is all about. Being coerced, manipulated or deceived so that one will be obedient and go along with these treatments is another form of birth rape. Some even consider making rude and discouraging remarks to influence the mother rather than empower her to be included in the definition. Moving a mother into certain positions without asking and telling her what to do are further examples of mistreatment.

Some deny the existance of birth trauma in mothers or believe that they or exaggerating, especially being that misconduct is rarely reported. Some 54% of women in one study had grounds for a complaint but did not file, which is a classic behavior of a person experiencing PTSD. Some go as far as to suggest that postpartum PTSD is caused by past sexual assault that is refreshed as a result of the traumatic birth, though many victims of birth rape have no history of abuse.

Anywhere from 3-10% of postpartum women suffer from PTSD after birth which can lead to postpartum depression. Six months later the rate is about 1.5%. Forty-three percent of those women develop postpartum depression. The American Psychiatric Association recognizes any event that causes "fear for the life of bodily integrity of the person or a loved one" to be cause for PTSD, and birth can definitely meet that requirement.

Among the symptoms of birth-induced PTD are obsessive thoughts about the birth; panic near the birth location; and flashbacks, nightmares, and disturbing memories of the birth. Generally feeling sad, afraid, anxious, or irritable can also be caused by PTSD. Some mothers with PTSD may behave differently toward their children, particularly the ones associated with the specific birth that caused the PTSD. Symptoms can last for a year but usually subside within a few months. It can take a lifetime for the wounds to fully heal, and relapses often occur.

It is recommended that birth professionals empower women to prevent birth trauma. Give her control. Show her that she is valued. Treat her with respect. Ask permission anytime you are performing an intervention or even touching her. If she asks you to stop, do so immediately. Above all, listen to her, and show her that you care about her and not just her baby. They also recommend a period of 'debriefing,' where the woman is encouraged to talk about her experience. This can be therapeutic and also help her recognize ways in which she was mistreated. She can chose then to confront the abuser, file a claim, or just walk away knowing that at least someone understands, believes, and recognizes the abuse.

Having been in birth since 1982, I am often asked to share my birth stories. I am finally writing them down. Please, if you are pregnant or nursing, use your discretion when reading. Not every story is perfect, but I write real life... as it happened, not as I would create it now. These stories have made me who I am... as a woman, a mother, a doula, and a midwife.

Saturday, August 07, 2004A Different Kind of Pain in Childbirth Note before beginning!

This can be seen as a VERY negative post. Even in that light, there absolutely is a balance... a mirror image of the goodness and love and kindness I have seen in birth, too. But this blogspot isn't the space for that. I will do that another time. This is for enlightenment of a different sort.

As most who are reading this blog know, I am also processing issues surrounding birthrape and how midwives (not just OBs and nurses) facilitate the birthrape experience for women.

(a definition in the making)

Birthrape: The experience of having fingers, scissors, and/or tools put/pushed/shoved inside a woman's vagina or rectum without her direct (or indirect) permission.

Being coerced, manipulated, or lied to regarding the health and safety of the baby or themselves so the midwife is able to do something to the mother's vagina, rectum, cervix, or perineum, usually with excuses; rarely with apologies.

Some find the definition expanded to:

The midwife taking the woman's Power by using disparaging comments, unsupportive expressions, speaking around her as if she is unable to hear or process requests or information.

and

Even though consent forms are signed in the hospital, birth center, and at home, consent for care does not include the manipulations or coercive words to get women to obey the caregiver.

I thought it was time I shared some of the thousands of comments I have personally heard that have facilitated birthrape over the years.

I share them and am writing about them and speaking about them and nearly screaming about them in the hopes that midwives will hear what they are saying that is sending their clients into therapy, pushing them to depressions that require medication and alternative therapies, keeping them from coming back to the midwife at all because of her Power Hunger and covert misogyny. Too many women (in my opinion) find Unattended Birth their only acceptable option after their experiences with professional caregivers in birth.

You see, most midwives talk a good game. They will say any number of things in pregnancy to lead the woman to believe she (the mom) is in control. I have sat through hundreds and thousands of prenatals with midwives and listened to the party line about how they believe in a woman to know, how they will "let" them labor how they want, how they will limit vaginal exams, etc. And then, when labor is in full swing, I sit by (or participate) in the amazing disregard for the woman's prenatal wishes and dreams of an unhurried, unfettered, un-directed birth.

I am not a part of the delusion or lies anymore.

Common Beliefs* Women in labor don't really want to use their birth plan.* Women in labor aren't able to verbalize their needs.* Women in labor don't know when they need to pee or drink or eat. * Women in labor don't know when to change positions.* Women in labor can't make decisions.* Women in labor want an epidural.* Once labor kicks in, they all want epidurals.

Directives That Disembody Her Being

* Lift her leg.* Move her to the bed.* Grab her knees.* Put her feet in the stirrups.* Put her hands on the grips.* Push her head to her chest.* Push her chin to her chest.* Put pillows under her head.* Put pillows under her butt.* Pull her down to the edge of the bed.* Push with her so she knows how to do it right.* Count for her so she knows how to do it right.

(while these next phrases end in periods and question marks... almost exclusively, the following words have been shouted at women... an exclamation mark is more appropriate, but there aren't enough in the computer to add them all)

Comments That Negate Her Intelligence (spiritual, physical, emotional, and intellectual)

* You aren't pushing right.* Push like this.* Quit making noise.* No, push longer.* Push like you are having a bowel movement.* Push the watermelon out.* Push the bowling ball out.* Don't push in your chest, push in your butt.* Push like you mean it.* What are you doing?* Can't you push harder?* Have you ever been raped? (asked in labor)* Are you an abuse survivor? (asked in labor)* Have you been abused? (asked in labor)

Coercive and Manipulative Remarks

* I need to get in there.* pressing knees apart - I need to do a vaginal exam.* C'mon, just let me see what is going on.* I'll do it quick and fast, I promise.* I promise to be gentle.* I just want to feel the baby's position.* I just want to see how dilated you are.* You asked me to be your midwife, now let me do my job, okay?* I'm a woman, too, I know how it feels... I promise to be gentle.* I remember how vaginal exams felt in labor, I promise to be gentle.* Do you want the baby to come out or not? Just open your legs.* Are you sure you are ready to be a mom?* You had no problem opening your legs 9 months ago.* Just let me break your water, it will speed things up.* If I break your water, the head will be applied better on the cervix.* If I break your water, prostaglandins will stimulate things nicely.* Here, drink this. (as Gatorade with cytotec is given to the mom)* You might feel a pinch. (as pitocin is injected into the vaginal vault)* I am just wiping up some stuff. (as pitocin on a gauze is pushed inside the vagina or rectum)* Here, drink this. (as blue and black cohosh are given without consent)* Here, put these under your tongue. (as homeopathics are given without information or consent)* I'm just feeling your cervix... it might hurt a little. (as manipulations to the cervix are done... from stripping the membranes to manual dilation)* I'm just feeling your cervix. (as cytotec is put onto the cervix)* Do you want your baby to die?* You don't know the seriousness of the situation.* You have been a martyr long enough.* Just take the medication.* Just get "your" epidural.* Would you like something for the pain? (in the middle of a contraction)* This will take the edge off.* It doesn't do anything to the baby.* If you were my daughter/sister/mother....* I have had three scheduled cesareans myself! I don't know what you are complaining about. (being wheeled into the OR)* Stop whining.* Why are you crying?* What is wrong with you? Are you trying to hurt your baby?* In this day and age, no one needs to suffer in childbirth anymore.* Mothers and babies died without hospitals 100 years ago.* Let me call the anesthesiologist... just talk to him about your options.* No, you can't eat... just in case you need a cesarean... and your labor is rather slow moving.* No, nothing by mouth after 7 centimeters. (or any number the caregiver randomly pulled out of her ass)* Only ice chips.* Oh, Bradley... they always have cesareans.* You wanted a homebirth? That's child abuse!* Are you one of those La Leche League people who nurse until the kid dates?* Do you vaccinate? (after discussion of no erythromycin in the baby's eyes)* You want your baby to go blind? (after refusal of erythromycin in baby's eyes)* Your baby might bleed to death. (after refusal of Vitamin K injection for the baby)* It's just antibiotics.* God, you have terrible veins!* Where are your veins?* (to the Licensed Midwife during a transport, a nurse asks) Do you know how to take a blood pressure? Did you do any?* Why did you wait so long?* Why did you get here so early?* You aren't in labor.* How would you not know if your water broke or not?* Can't you stop moaning?* Be quiet!* Oops, your water broke! (while using fingernails or fingers to break it on purpose)

Whispering to Other Birth Attendants

• My god, I wish she would hurry up.* I am so bored!* She is going so slow.* I wish she would let me break her water.* My baby needs to nurse, I need to go home.* My boobs are going to burst if I don't go home and nurse. She needs to hurry up.* I am so tired.* I want to go home.* I am going to talk her into letting me break her water so she will hurry up.* I am going to talk her into letting me manually dilate her so she will hurry up.* I need her to hurry up.* She's holding back. There must be some emotional barrier we haven't found yet.* I bet she was abused. Look how she: keeps her legs together/cries with exams/doesn't want us to touch her/doesn't take her clothes off/won't take her shirt off/won't relax enough to let the baby out/is afraid to be a parent/hasn't worked through her issues/has body image issues/has eating issues/is fat/is thin/lives in her head/isn't in touch with reality* She is so noisy.* She is too quiet.* She needs to let go.

I am exhausted writing this much pain. I know there are hundreds of thousands of remarks that have been said that I haven't been witness to and I encourage women who have had them said to them to email me privately so I might start a list that lets caregivers know what not to say to women during pregnancy, labor, birth, and postpartum.

Email to: Barb Herrera - msgardenia@cox.net

Your names, of course, are completely private. Your words, however, need to be heard!

Let's shout together.

My mind cannot stop the thinking about the birthrape issue and NO ONE in my life, not even my partner, wants to hear one thing about it. A childbirth educator friend said she would talk and we could process, but she is a client of mine, albeit my hypno-therapist, but I have horrid feelings of guilt I have begun exploring about HER birth. She has told me she loved her birth, even when I sobbed speaking about how I hated what I did to her at her birth (retrospectively; after my hands-off birth). It doesn't make my heart rest any easier... well, maybe a little.

I can't stop diarrhea-ing.

I think the insanity and birthrape guilt are separate and together. Maybe I am paying for my past now instead of later.

Just dig in.

As I learned to be a midwife, I did horrible things to women in the name of education. I have held women's legs open ("to get the baby out"). I have pulled placentas out ("to learn how to get one out that needs help or if the mom is bleeding"). I have squished a woman's belly until I could nearly feel her spine, which is, actually, the wording used by the teachers (plural): Push until you find her spine ("to keep her from hemorrhaging and expel clots"). I have pulled placentas until cords have fallen off. I have grabbed women's nipples and shoved them into their babies' mouths. I have done vaginal exams on women who were screaming NO! I have coerced women to allow me into their vaginas for exams. I have done "finger forceps" [a misnomer] (using my fingers to press the ischial spines open wider for a baby to come through faster). I have ruptured membranes because I needed to learn how. I have manually dilated cervices that did not need to be touched because I needed (or thought I needed) to learn how to do it in an emergency. I have manually dilated a cervix on a woman having a waterbirth (and I wasn't wearing gloves) and got her cervical flesh under my fingernails.

As a doula and student, I stood by and watched as women screamed to be left alone. I watched midwives with 3 inch fingernails shove cervices from 3-10 in a few minutes. I watched as women had cytotec inserted into their vaginas secretly. I watched as women unknowingly drank cytotec from Gatorade bottles. I witnessed pitocin being secretly injected into the vaginal vault to projectile a baby in second stage arrest. I witnessed pitocin being put on gauze and put in women's vaginas without their knowledge. I watched as the gauze was put in their rectums without their knowledge. I have seen women sutured who might not otherwise need it simply because someone needed training. I have seen OBs cut an episiotomy because they are in a hurry. I have heard evil things coming from OB's mouths towards clients and stood by and said nothing. I have heard even more evil things come from midwives and stood by and said nothing. I have seen and heard women be screamed at to shut up, grow up, that she asked for it by opening her legs 9 months ago, that she gets what she deserves. I have seen a woman slapped by a midwife. I have seen a midwife, on more than one occasion, hang a baby upside down and slap the baby up and down the back to revive him/her. I have seen, on more than one occasion, midwives take a fainted woman's nipples and twist them nearly off to revive the woman.

I have seen many illegal maneuvers that have saved women trips to the hospital and have learned amazing amounts of information that I would never use unless a woman or baby were dying in my arms. I have NOT done other equally unethical acts... have not ever cut an episiotomy because I needed to practice... have not sutured because I needed to practice... have not ever used forceps or vacuum extractor. I have learned how to birth a baby in the caul. I have learned how to sit and wait from long second and third stages. But it doesn't remove one iota of the pain I feel. There is no catharsis.

I am the enemy of many women. I am their pain. I embody it. I created it. I am more filled with shame than there are words to describe.

Does it make any difference that I have grown to not do these things? Did I have to walk that path to get where I am? Why did I love the learning I experienced? Why did I get high from all the energy and the uncertainty? Do I really believe I wouldn't be the midwife I am today if I didn't know all I know? Am I better able to speak the language of the enemy because I am the enemy? Do I have any right speaking to the women whose hearts bleed and whose bodies are mutilated?

I pray to find the balance of peace and forgiveness... all within my Self.

With the advances in nutrition and fluid replacements, most women survive hyperemesis gravidarum with fewer life-threatening complications. However, being treated and surviving hyperemesis can cause psychological problems for some people. Survivors of hyperemesis may have problems with self-esteem, intimacy, guilt, and conditioned food aversions. Women may experience anxiety and depression related to receiving inadequate treatment for hyperemesis, fear of the hyperemesis recurring in future pregnancies, and having to face the fear of harm or death to herself and/or her unborn child when pregnant. Some survivors of hyperemesis experience trauma-related symptoms, such as avoiding situations, continuously thinking about problems, and being over-excited. These symptoms are similar to symptoms experienced by people who have survived highly stressful situations, such as combat, natural disasters, rape, or other life-threatening events. This group of symptoms is called post traumatic stress disorder (PTSD) or post traumatic stress syndrome (PTSS). It is more common in women than in men. People with histories of hyperemesis are at risk for PTSD. The physical and mental stress of having a potentially life-threatening disease (threatening them or their unborn child), not being believed by health professionals, receiving treatment for hyperemesis, and living with unexpected and possibly uncontrolled threats to one's body and life (and one's unborn child) during pregnancy are traumatic experiences for many hyperemetic women. Hyperemetic women experience pain, distress, extreme fatigue, muscle weakness, incessant nausea and/or vomiting. The sensation of suffocation that accompanies forceful, unrelenting retching or vomiting can be quite traumatic. In fact, inducing that sensation is a torture technique that is documented to cause psychological trauma. Hyperemetic women also may undergo painful and invasive procedures, as well as be faced with possible guilt as they decide whether they can continue the pregnancy when they are so sick. Relationships are strained and she may feel misunderstood and alone. They may be in the hospital for a few days or weeks, leading to feelings of frustration, isolation and loss of control. They may be unable to care for themselves or their family for weeks or months. These experiences may lead to feelings of helplessness, especially for women who have certain risk factors, such as having little social support, experiencing a trauma, being victimized in the past, or having a history of mental disorder.Applying PTSD to Hyperemesis GravidarumOne problem health professionals have in determining if a hyperemetic woman has PTSD is figuring out what exactly is the cause of trauma. Because the hyperemesis experience involves so many upsetting events, it is much more difficult to single out one event as a cause of stress than it is for other traumas, such as natural disasters or rape. For hyperemesis women, the stressful incident may be related to frequent episodes of vomiting, many relapses with a worsening of symptoms, painful or stressful procedures, fear of death, loss of unborn child, complications such as severe infection or convulsions, scary scenes such as vomiting blood, treatment delays or insufficient treatment, and not being taken seriously. Some women may also experience abandonment and abuse, causing further trauma.DiagnosisPTSD is defined as the development of certain symptoms following a mentally stressful event that involved actual death or the threat of death, serious injury, or a threat to oneself or others. These events may include being diagnosed with a potentially life-threatening illness. In the case of hyperemesis, the illness threatens the baby and mother if left untreated or inadequately treated. Many hyperemetic women fear death, especially those with more severe symptoms that do not respond to prescribed treatment.These events may cause responses of extreme fear, helplessness, or horror and may trigger PTSD symptoms. These symptoms include re-experiencing the trauma (nightmares, flashbacks, and interfering thoughts), continuously avoiding reminders of the trauma (avoiding situations, responding less to people, and showing less emotion), and being continuously excited (for example, having sleeping problems or being overly defensive, watchful, or irritable). Other common emotional responses include unhappiness, guilt over actions taken or not taken, and overwhelming loss. It is common for some women with hyperemesis to experience this for months or years after pregnancy.PrevalenceIn hyperemesis, as in other stressful major life events, over-excitability, avoiding certain thoughts and reminders, and having intrusive thoughts may occur during or after pregnancy. The number of women with these symptoms is unclear and has not been studied to date. It has been estimated that approximately 10% of women with hyperemesis have severe symptoms. Thus, the number with PTSD may be close to that number, or perhaps greater. It is not uncommon for women to seek information on hyperemesis for many years postpartum, trying to get answers to their questions. They may even become quite emotional discussing or thinking about their experience for years afterwards. Childbirth is also a known risk factor for PTSD. If the childbirth experience is perceived as traumatic due to complications or difficulties, the risk of PTSD is likely greater in women with hyperemesis. Future pregnancies may bring about significant anxiety and panic attacks, symptoms of PTSD. PTSD is often overlooked or undiagnosed in women with a history of hyperemesis. Instead, they may be diagnosed with depression and anxiety that may be chronic. In studies of cancer patients, some have these symptoms even 6 years after their last treatments. It is unknown how long women with hyperemesis will experience symptoms. Some hyperemesis survivors may have higher levels of general mental distress. People with a history of PTSD may be at risk for developing ongoing emotional problems.Symptoms typical of PTSD may be seen in family members of hyperemesis survivors. These symptoms may be due to family members having to face the woman or baby's possible death, as well as witnessing painful treatments and relentless vomiting. It is not uncommon for children to have anxiety and fear the death of their mother. Behavioral changes may result especially if the child is not reassured and their world is greatly altered by the mother's illness. These symptoms may lessen over time, however, assistance may be needed from health professionals.Causes and Risk FactorsAs many as one-third of people who experience traumatic events may develop PTSD. It is caused by an extremely upsetting event; however, this one event alone does not explain why some people get PTSD. Not everyone who experiences these upsetting events develops PTSD. For some people, mental, physical, or social factors may make them more likely to experience it. PTSD symptoms develop due to both adapting and learning.Adapting explains the fear responses caused by certain triggers that were first associated with the upsetting event. Triggers (such as, smells, sounds, and sights) that occurred at the same time as symptoms (for example, bathroom cleaners smelled while vomiting) may cause anxiety, upset, and fear when occurring alone, even after the trauma has ended. Once established, PTSD symptoms are continued through learning. That is, avoiding certain triggers continues because this avoidance prevents unpleasant feelings and thoughts.The most critical factors in determining which women develop PTSD due to hyperemesis seem to be the severity and duration of the symptoms. The suddenness of the onset and the level of threat to her or her unborn child's life and health are also important.While the type of event is the main factor in how a person responds to a traumatic event, other individual and social factors may also play a role. Previous psychological problems, history of trauma, high levels of mental distress, and ineffective coping skills have been linked to a risk of PTSD. Genetic and other biologic factors (for example, hormone changes) may also make some people more at risk for PTSD. The amount of social support available has also been shown to affect the risk of PTSD, and may influence severity of hyperemesis as well.Factors That May Increase The Risk Of PTSD After Hyperemesis Gravidarum• Medical Complications• History of mental illness• Prolonged symptoms• Severe symptoms• Sudden onset• Delay in diagnosis/care• Inadequate treatment• First HG pregnancy• Genetic/biological factors• Hormone levels• Stress level• Social support• Coping skills• Painful procedures• Disinformation• History of trauma• Loss of unborn child• Perceived threat to self• Disbelief by others of severity• Inability to care for self/familyAssessmentWomen with hyperemesis should be assessed for signs of anxiety and depression during pregnancy and after delivery. At the same time, she should be evaluated for signs of PTSD. This is especially true in women with a history of hyperemesis and/or other traumas. Future pregnancies may trigger a return of PTSD symptoms. While these women may have problems adjusting to a recurrence of hyperemesis and its treatment, their PTSD symptoms may vary, and be greatest at the beginning of pregnancy or possibly postpartum. She may avoid intimacy for fear of pregnancy. This further strains her relationships. Postpartum depression may also be more prevalent among these women and screening should be done at intervals after delivery.Family members should also be educated on signs to watch for to ensure these women get the help they need. Symptoms of PTSD usually begin within the first 3 months after delivery, but sometimes they may not appear for months or even years afterwards. Therefore, hyperemesis survivors and their families should be involved in long-term monitoring.Some people who have experienced an upsetting event may show early symptoms without meeting the full diagnosis of PTSD. However, these early symptoms predict that PTSD may develop later. Early symptoms also indicate the need for repeated and long-term follow-up of hyperemesis survivors and their families.Diagnosing PTSD can be difficult since many of the symptoms are similar to other psychiatric problems. For example, irritability, poor concentration, increased defensiveness, excessive fear, and disturbed sleep are symptoms of both PTSD and anxiety disorder. Other symptoms are common to PTSD, phobias, and panic disorder. Some symptoms, such as loss of interest, a sense of hopelessness, avoidance of other people, and sleep problems may indicate the woman has PTSD or postpartum depression. Even without PTSD or other problems, normal reactions to unrelenting vomiting/retching and treatment of a potentially life-threatening disease can include interfering thoughts, separating from people and the world, sleep problems, and irritability.TreatmentThe chronic and sometimes disabling effects of PTSD mean the disorder needs to be identified and treated quickly. However, the avoidant symptoms that appear with PTSD often keep the woman from seeking help. Further, signs of postpartum depression may make an accurate diagnosis challenging. Health professionals may be too quick to treat the depression since she has recently been pregnant, and fail to assess further and accurately diagnose PTSD. Therapies used are those used for other trauma victims and involve more than one type of therapy.The crisis intervention method tries to lessen the symptoms and return women to their normal or pre-pregnancy level of functioning. The therapist focuses on solving problems, teaching coping skills, and providing a supportive setting for the woman.Thinking-behavior methods may be helpful. Some of these methods include helping the woman understand symptoms, teaching coping and stress management skills (such as relaxation training), reforming one's thinking, and trying to make the woman less sensitive to conditioned aversions.Support groups may also help people who experience post-traumatic stress symptoms. It may be impossible to find a group of women who have experienced hyperemesis. However, there are several online support groups that may be supportive. Some mental health professionals specialize in women's health and may be most experienced in working with women suffering from complications of pregnancy.For women with severe symptoms, medications may be used. These include antidepressants, antianxiety medications, and when necessary, antipsychotic medications.Updated on: Aug. 09, 2006

experienced physical or sexual abuse in childhood, women who have been raped. Researchmakes quite clear however that it is not only these women who suffer post-natal PTSD, and thattreating ALL women with humanity and respect would go a long way towards helping those whoare particularly vulnerable. A woman who had been raped as a teenager described how a doctor‘ushered in a gaggle of students to stare at my genitals without my consent – it brought back thehorror of the rape all over again’. But no woman should have to endure this affront to her dignity.Women who talk about their traumatic experience of birth are often told: ‘put it behind you, begrateful you’ve got a healthy baby’; or ‘it’s just your hormones’. Or it is implied that they are mad,crazy, unbalanced and over-reacting. Birth Afterthoughts schemes and other ‘debriefing’exercises can help – although they sometimes treat women not as patients but as potentiallitigants.The growth in research and training on post-natal PTSD is making it less likely that traumatizedwomen can be dismissed or their concerns trivialized, and more likely that medical professionalswill be held accountable.Accountability – in the context of PTSD – is not merely about the medical management of labour.It is about the capacity of obstetricians and midwives and other caregivers to behave withhumanity - and with respect for the essential rights and dignity of the labouring woman.ReferencesAyers, S. and Pickering, A. (2001) Do women get posttraumatic stress disorder as a result ofchildbirth? A prospective study of incidence. Birth 28(2): 111-118.Drife, J. and Lewis, G. (2001) Why Mothers Die 1997-99: The Confidential Enquiries intoMaternal Deaths in the UK. London: RCOG Press.Laurence, R. 1997. Post-traumatic stress disorder after childbirth: The phenomenon of traumaticbirth. Canadian Medical Association Journal 156(6): 831-835.Robinson, J. (2002) Post-traumatic stress disorder: A consumer view, Pp. 313-322 in MaternalMorbidity and Mortality, edited by A.B. MacLean and J. Neilson. London: RCOG Press.Soderquist, J, Wijma, K, and Wijma, B (2002) Traumatic stress after childbirth: The role ofobstetric variables, Journal of Psychosomatic Obstetrics and Gynecology 23(1): 31-39.Information about the Birth Crisis Network is available on:http://www.sheilakitzinger.com/Birth%20Crisis.htm

Thyroid Disorders
and Pregnancy

Gerard N. Burrow, MD, FRCP
Vice Chancellor for Health Sciences and Dean, School of Medicine
University of California, San Diego, La Jolla, California

Thyroid Disorders and Pregnancy

Thyroid disease is present in 2-5 percent of all women and 1-2 percent of
women in the reproductive age group. Not unexpectedly, thyroid problems are
common in women who are pregnant. In this article we will view pregnancy
broadly to include the antepartum (before pregnancy) and postpartum (after
pregnancy) periods, as well as pregnancy itself. Both the baby's and mother's
well-being are equally important. In this review we will outline our approach
to the common thyroid disorders encountered in pregnancy based on questions
frequently asked by our own patients.

Spectrum of Thyroid Disease in Pregnancy

Several of the thyroid disorders which tend to occur during pregnancy are
autoimmune in nature. By this we mean that the body develops antibodies
directed against thyroid cells, which then affect the way the thyroid gland
functions. Antibodies which damage the thyroid cells may result in lymphocytic
thyroiditis (inflammation of the thyroid), also known as Hashimoto's disease.
These damaging antibodies can reduce the function of the thyroid and lead to
hypothyroidism. On the other hand, your body can make antibodies against
thyroid tissue which can stimulate thyroid cell function. In this case,
hyperthyroidism due to over-function of the thyroid (Graves' disease) may be
the result.

Postpartum thyroiditis is a recently discovered problem that spans the
spectrum of both hyper- and hypothyroidism. This condition, which tends to
occur immediately after pregnancy, may produce antibodies which damage thyroid
tissue, thereby releasing thyroid hormone passively into the bloodstream and
producing hyperthyroidism. During the recovery phase, thyroid levels may fall,
producing either temporary or permanent thyroid failure. Since this condition
is common, occurring in 8-10 percent of all women after pregnancy, postpartum
thyroid testing is advisable for all women.

Thyroid nodules, goiters, and other thyroid problems are also sometimes
first detected in pregnancy but are less common.

Thyroid Disease in the Mother During Pregnancy

Hypothyroidism. If hypothyroidism is suspected in a pregnant patient,
the physician can perform a TSH blood test. Just as in non-pregnant women, the
TSH will be increased if hypothyroidism is present. If a woman is already being
treated with thyroxine when she becomes pregnant, she should continue to take
this medication during pregnancy. Thyroxine is safe to take and is well
absorbed during pregnancy. Although there is usually no need for a dose change,
some women require somewhat higher doses when they are pregnant. Physicians
generally monitor the TSH level to detect even mild hypothyroidism and increase
the thyroxine dose, if necessary.

Hyperthyroidism. Thyrotoxicosis (hyperthyroidism) during pregnancy,
most often due to Graves' disease, presents a challenge for diagnosis and
treatment because of unique fetal and maternal considerations.

The risk of miscarriage and stillbirth is increased if thyrotoxicosis goes
untreated, and the overall risks to mother and baby further increase if the
disease persists or is first recognized late in pregnancy. The diagnosis is
suggested by specific physical signs such as prominent eyes, enlarged thyroid
gland, and exaggerated reflexes, and is confirmed by markedly elevated serum
thyroid hormone levels. As noted above, radioactive iodine scans or treatment
are never performed in pregnancy. However, if a thyroid scan is inadvertently
done in pregnancy, this should cause little concern, since the amount of
radioactivity delivered to the fetus is barely above the background level in
the environment

On the other hand, if radioactive iodine treatment is inadvertantly
administered in pregnancy, this raises concerns about the radiation effects on
the developing fetus in early pregnancy. The amount of radiation may approach
levels which can be harmful and, after appropriate counseling, some patients
may opt for a therapeutic abortion. Still a number of completely normal infants
have been born in this situation. Later in pregnancy radioactive iodine can
destroy the fetal thyroid, but this is probably not a sufficient reason to end
the pregnancy, since recognition and treatment of hypothyroidism shortly after
delivery usually assures normal growth and development in the child.

The treatment of choice for thyrotoxicosis during pregnancy is antithyroid
medication, either propylthiouracil or methimazole, since radioactive iodine
cannot be used. Propylthiouracil (PTU) remains the drug of choice, since it
does not cress the placenta as well as methimazole. The initial goal is to
control the hyperthyroidism and then use the lowest medication dose possible to
maintain the serum thyroid hormone levels in the high normal range. In this way
the smaller doses of medications are used, and there seems to be little risk to
the baby. If a mild allergy to one of these medications develops, the other
medication may be substituted. If there is a problem with taking pills or more
severe drug allergy, then an operation may be performed to remove most of the
thyroid gland. This is usually done in the middle part of the pregnancy.
Fortunately, it is rarely necessary.

The natural course of hyperthyroidism in pregnancy is for the disease to
become milder or remit totally near term. In many patients antithyroid
medications can be tapered to low levels or even discontinued. For those
patients who are not so fortunate, it is important to maintain control of the
hyperthyroidism throughout pregnancy to avoid severe thyrotoxicosis (thyroid
storm) developing during labour and delivery. If this does develop, additional
acute treatment with beta-adrenergic blocking drugs such as propranolol
(Inderal) and high doses of nonradioactive iodine are used. Long-term treatment
with these agents is not advised in pregnancy, although some physicians use
propranolol when the disease is first diagnosed to control symptoms until the
antithyroid medications have had a chance to work.

Fetal Thryoid Disease

Antithyroid medications, nonradioactive iodine and, very rarely, maternal
thyroid antibodies can all cross the placenta and cause hypothyroidism in the
baby. Nonradioactive iodine, which is present in some medications, including
some cough medications, can cause a goiter in the fetus, making delivery
difficult or causing respiratory obstruction. For this reason, iodine
containing drugs should never be used in pregnancy except in the case of
thyroid storm. Unfortunately, there is no simple blood test to assess the
baby's thyroid function in the womb, although measurements of thyroid hormone
or TSH levels in the amniotic fluid sac have been used in research studies.
Plain X-rays sometimes show delayed bone development in fetal hypothyroidism,
but this test is usually not recommended. Screening for hypothyroidism at
birth, now done routinely in North America on
all babies, identifies the need for early short- or long-term thyroxine
treatment, with excellent long-term follow-up results.

Fetal thyrotoxicosis (hyperthyroidism) occurs occasionally due to transfer
of maternal thyroid-stimulating antibodies across the placenta. Most often, the
mother herself has hyperthyroidism which is being treated with antithyroid
drugs that also passively treat the baby by crossing the placenta. Sometimes,
however, the mother's thyrotoxicosis occurred in the past and was controlled by
either radioactive iodine treatment or an operation in which the mother's
thyroid gland was removed. In such a situation the mother has less thyroid
tissue and cannot be hyperthyroid, even though she continues to have thyroid
stimulating antibodies in her blood. Since the mother is well, fetal
thyrotoxicosis may not be suspected. Clues to the presence of fetal hyperthyroidism
are fetal heart rate consistently above the normal limit of 160 beats per
minute and the presence of high levels of thyroid stimulating antibodies in the
mother's blood.

All women with Graves' disease or a history of Graves' disease should be
tested for thyroid-stimulating antibodies late in pregnancy. The consequences
of untreated fetal thyrotoxicosis include low birth weight and head size, fetal
distress in labour, and neonatal heart failure and respiratory distress.
Administration of antithyroid drugs to the mother during pregnancy can treat
the baby in this situation. Close follow-up and continued treatment is required
after delivery.

Postpartum Thyroid Disease in the Mother

Pre-existing Thyroid Disease. For pre-existing hypothyroidism,
thyroid hormone treatment is continued after delivery and breast feeding is
encouraged. Thyroid hormones do not get into breast milk in significant
amounts.

Graves' disease (hyperthyroidism due to a diffusely overactive thyroid) is
prone to relapse or worsen in the postpartum period. If that happens,
antithyroid drugs can be started or their dose increased, or radioactive iodine
can be given if the mother is not breast feeding. Women taking PTU
(propylthiouracil) may breast feed, since little of this drug crosses into the
milk. Nursing is also possible for women who take methimazole, although more of
the drug gets into breast milk. In both cases the baby's thyroid function
should be monitored. Definitive therapy with radioactive iodine should be
considered, although many breast-feeding women will wish to postpone this,
since some of the mother's radioiodine crosses into her baby through the breast
milk.

Postpartum Thyroiditis. Postpartum thyroiditis may occur in 8 to 10
percent of women. This disease also occurs in the nonpostpartum period, as well
as in men, and is probably an autoimmune thyroid disease related to Hashimoto's
thyroiditis. Typically, it consists of a temporary period of hyperthyroidism
lasting from six weeks to three months postpartum, followed by hypothyroidism
between three and nine months after delivery. Women at risk include those with
a previous history of postpartum thyroiditis or those who can be shown to have
thyroid antibodies in their blood but are not taking thyroxine. Usually, no
treatment or only symptomatic treatment is required for the hyperthyroid phase,
and a short course of thyroxine treatment for six to twelve months is
sufficient for the hypothyroid phase. Some women do not recover from the
hypothyroid phase and, therefore, require long-term thyroid replacement
therapy.

During the first three months after delivery, symptoms of fatigue,
depression, and impairment of memory and concentration are common and often
unrelated to a woman's thyroid hormone level. However, after this time, hypothyroid
women have more of these symptoms and may feel better if their hypothyroidism
is corrected by thyroid hormone treatment.

Not every women who has an emotional disorder after pregnancy will be found
to have thyroid dysfunction as the cause of her problem. Thus in one recent
clinical study, no increased incidence of thyroid dysfunction was found in a
group of women with postpartum psychoses. Nevertheless, it is still reasonable
to perform thyroid tests (including a TSH blood level) in those women who do
experience emotional disorders following pregnancy.

Summary

In dealing with thyroid disease in pregnancy, the physician and patient
should be aware of problems that occur before and after, as well as during the
actual pregnancy. There should be equal concern for the welfare of both the
mother and baby. Fortunately, most thyroid conditions can be recognized,
problems can be anticipated, and effective treatment is available. The outcome
is almost always a healthy one, for both the mother and her baby.

Background The effect of pregnancy on the risk of breast canceris
not clear. We tested the hypothesis that the risk of breastcancer
increases transiently after pregnancy but then fallsto a level
below that of age-matched nulliparous women.

Methods We conducted a case-control study of a nationwide cohortin Sweden,
using a computerized record linkage between the CancerRegistry and
the Fertility Registry. The study subjects werewomen born from 1925
through 1960 who were resident citizensof Sweden at the time of the 1960
census. A total of 12,666patients with breast cancer were compared
with 62,121 age-matchedcontrol subjects. We used conditional
logistic regression toestimate odds ratios for the development of
breast cancer atdifferent ages, according to maternal age at first
delivery(in uniparous as compared with nulliparous women) and age
atsecond delivery (in biparous as compared with uniparous women).

Results Uniparous women were at higher risk of breast cancerthan
nulliparous women for up to 15 years after childbirth andat lower
risk thereafter. The excess risk was most pronouncedamong women who
were older at the time of their first delivery(odds ratio 5 years
after delivery among women 35 years oldat first delivery, 1.26; 95
percent confidence interval, 1.10to 1.44). Women who had two
pregnancies had a less strikingincrease in risk.

Conclusions Pregnancy has a dual effect on the risk of breastcancer: it transiently increases the risk after childbirth butreduces
the risk in later years. In women with two pregnancies,the
short-term adverse effect is masked by the long-term protectionimparted
by the first pregnancy. A plausible biologic interpretationis that
pregnancy increases the short-term risk of breast cancerby
stimulating the growth of cells that have undergone the earlystages
of malignant transformation but that it confers long-termprotection
by inducing the differentiation of normal mammarystem cells that
have the potential for neoplastic change.

From the Divisions of Gynecologic Oncology
and Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology,
Radiation Oncology, and Pharmacology, University of Iowa Hospitals and Clinics,
Iowa City, Iowa.

Objective: To compare the prognoses of women diagnosed withcervical
cancer during pregnancy with the prognoses of thosediagnosed within
6 months after delivery and to assess the effectof vaginal delivery
on recurrence risk and prognosis.

Methods: A matched case-control study of women with cervicalcancer
diagnosed during pregnancy or within 6 months of deliverywas
performed. Fifty-six women had cervical cancer diagnosedduring
pregnancy and 27 within 6 months after delivery. Controls(cervical
cancer diagnosed at least 5 years since last delivery)were matched
one-to-one with cases based on age, histology,stage, treatment, and
time of treatment.

Results: Among postpartum women, four had stage IA disease,15
had stage IB1 or IB2, and eight had stage IIA or higher disease.Eleven
had radical hysterectomies and 14 had radiation therapy.Two with
stage IA1 disease were treated with vaginal hysterectomies.One of
seven patients who had cesareans developed a local anddistant recurrence.
In contrast, ten of 17 (59%) who deliveredvaginally developed
recurrences (P = .04). In multivariate analysis,vaginal
delivery was the most significant predictor of recurrence(odds
ratio [OR] 6.91; 95% confidence interval [CI] 1.45, 32.8),followed
by high stage (OR 4.66; 95% CI 1.05, 20.8). The survivalfor
patients diagnosed in the postpartum period was significantlyworse
than for controls.

Conclusion: Women diagnosed postpartum had worse survival thanthose
diagnosed during pregnancy and were at significant riskof recurrent
disease, particularly if they delivered vaginally.Therefore,
pregnant women with cervical cancer should be deliveredby cesarean.

Invasive cervical carcinoma during pregnancy is relatively uncommonbut
remains the most common malignancy associated with pregnancy.Its
incidence is about 0.05% among all pregnant women.Thus,most institutions have
limited experience treating these women.

Pregnancy is a good time for cervical screening because cytologyroutinely
is done during prenatal care. However, 48–49%of cervical cancers
associated with pregnancy are diagnosedwithin 6 months of delivery.Most authors have combined womendiagnosed postpartum with
those diagnosed during pregnancy.It is extremely unlikely that all
these women developed newcancers subsequent to delivery.
Approximately half of cervicalcancers associated with pregnancy are
incorrectly diagnosedduring pregnancy, the reasons for which have
not been explored.The effect of delivery mode on outcome and
prognosis has beendescribed only in small case reports.

Most authors agree that pregnancy does not alter the outcomesof
women with cervical cancer. Some suggested that prognosesmight be
worse for women diagnosed in later pregnancy. Concernsabout vaginal
delivery through a cervix with malignancy includehemorrhage and
tumor dissemination at delivery. Some authorshave recommended that
cesarean be performed solely for obstetricindications. Most studies
have not analyzed separately the womenwho were diagnosed
postpartum. The objectives of our study wereto evaluate the
outcomes of women diagnosed with cervical cancerduring pregnancy
and within 6 months after delivery, to identifypossible reasons for
lack of diagnosis during pregnancy, andto assess the effect of
vaginal delivery on recurrence riskand prognosis.

Second to appendicitis,
gall bladder removal is the most common surgical condition encountered during
pregnancy, says Dr Christy Dibble, director of the Gastrointestinal Endoscopy
Service Program in Women's Digestive Disorders at Women and Infants Hospital
in Providence, Rhode Island. The National Institute of
Diabetes and Digestive and Kidney Diseases (NIDDK) notes that women between the
ages of 20 and 60 are twice as likely to develop gallstones as are men.

Pregnancy, as well as
estrogen and birth control use, put us at a higher risk for developing gall bladder
problems. In fact, Dibble says two to four percent of pregnant patients are
found to have gallstones during their pregnancy ultrasounds.

Symptoms
Symptoms are often called a gallstone "attack" because they occur
suddenly -- often following fatty meals and during the night. According to the
NIDDK, symptoms typically include:

Steady pain in the upper
abdomen that increases rapidly and lasts 30 minutes to several hours

Pain in the back between the
shoulder blades

Pain under the right shoulder

Nausea or vomiting

Abdominal bloating

Recurring intolerance of
fatty foods

Belching

Gas and indigestion

If, in addition, you
experience any of the following symptoms, you need to see a doctor immediately:

Sweating

Chills

Low-grade fever

Yellowish skin or whites of
eyes

Clay-colored stools

During an attack, the the
stone gets in the way, and the gall bladder "pushes against the blockage
of the stone, which causes pain. Then the gall bladder relaxes, and the pain
goes away," Bowen says. "After a while, if the gall bladder continues
to be inflamed, the patient may get intermittent episodes of abdominal
discomfort causing nausea, belching, etc. Then the gall bladder is scarred and
inflamed even further. [It] gets worse over time."

Treatment
Surgery to remove the gall bladder (cholecystectomy) is the most common
treatment for stones; more than 500,000 Americans undergo the procedure each
year. (Those who have gallstones but no symptoms usually do not need
treatment.)

Most commonly, the surgery is done with a laparoscope, using a procedure
that can be performed during pregnancy. The surgeon makes several tiny
incisions in the abdomen and inserts surgical instruments and a miniature video
camera into the abdomen. Outside of pregnancy and when a laparoscope can't be
used, a large incision across the abdomen is necessary. This is called
"open surgery," and is required in only about 5% of gall bladder
operation.

The epidemiology of postpartum infections has not been well characterized.
In part this is because of the limitations of surveillance systems, which
usually monitor infections that are recognized during hospitalization. Most
postpartum and nonobstetrical postsurgical infections, however, occur after
hospital discharge . Decreasing lengths of hospital stay may further compromise
detection of these infections.

Conclusion

Accurate assessment of the epidemiology of postpartum infections has been
hampered by the limitations of surveillance systems for identifying these
infections, particularly infections detected after hospital discharge. In our
study population, use of inpatient and ambulatory surveillance methods revealed
that postpartum infections requiring medical attention were common following
both vaginal delivery (5.5%) and cesarean section (7.4%). Mastitis and urinary
tract infections accounted for >80% of these infections. The proportion of
these infections directly attributable to health-care practices cannot be
determined from the information available. Our study also does not address whether
these infections were associated with modifiable (and therefore potentially
avoidable) risk factors, for example, suboptimal administration of
perioperative prophylaxis during cesarean section or bladder catheterization.

Nearly all postpartum infections became manifest after hospital discharge
(94%). Furthermore, most (74%) of these post discharge infections were
diagnosed and treated entirely in the ambulatory setting without the patients'
returning to the hospital where they delivered for evaluation or treatment,
emphasizing the need for post discharge surveillance methods that are not
dependent on hospital-based data.

In conclusion, our results indicate that
postpartum infections requiring medical attention are common and that most
postpartum infections occur after hospital discharge, so that use of routine
inpatient surveillance methods alone will lead to underestimation of postpartum
infection rates. Use of automated information routinely collected by HMOs and
insurers allows efficient identification of women who are very likely to have
postpartum infections that are not detected by conventional surveillance.
Information resulting from more complete surveillance could be used to identify
settings with unusually high or low infection rates to identify practices
associated with lower infection rates. This information could then be used to
focus, motivate, and assess the effectiveness of practice changes aimed at
improving infection rates in all settings. Additional research is needed to
evaluate the generalizability of this surveillance methodology to other
health-care provider and insurer systems and to assess resource utilization
associated with these infections.

Objectives: Healthcare associated infection (HAI) incidence rates
after delivery range from 0.26% to 20.3% according to the mode of delivery, the
maternity activity, women risk factors. Data on HAI surveillance in maternity
units are lacking. The Mater Sud-Est Study Group is a HAI continuous
surveillance network on maternity units located in south eastern France.
We report changes in risk-adjusted HAI rates over a 6-year long surveillance
period in this maternity units network.

Methods: 161,077 vaginal deliveries and 37,074 cesarean deliveries
were included in the surveillance between January 1st 1997 and
December 31st 2003. We studied the changes in four HAI: endometritis and
Urinary tract infection (UTI) after vaginal deliveries, surgical site infection
(SSI) and UTI after cesarean deliveries. We used a logistic regression modeling
to estimate risk-adjusted HAI rates. The year of delivery was considered as a
risk factor. The trend of risk-adjusted HAI rates over the study period was studied
by a linear regression of the year-of-delivery odds ratios for each targeted
HAI.

Results: The rate of endometritis and UTI after vaginal deliveries
was 0.3% (534/161,077) and 0.5% (728/161,077) respectively. Over the study
period the decrease in endometritis odd ratios was statistically significant.
We found no statistically significant trend in vaginal delivery's UTI.

The rate of SSI and UTI after cesarean deliveries was 1.5% (571/37,074) and
1.8% (685/37,074) respectively. Over the study period the decrease in SSI and
UTI odd ratios was statistically significant.

Conclusion: These findings highlight the positive effect of
participating in a surveillance network for infection control and for
improvement of care.

-------------------------------------------------------------------------------------------------------Does a Cesarean section delivery always cost more than avaginal delivery?Vahé A. Kazandjian PhD MPH,C. Patrick Chaulk MD MPH,Sam Ogunbo Phand Karol Wicker MHSAbstractThere is evidence that average total charges per episode of child birth depend on maternal plus child length of stay, neonatal intensive care unit (NICU) utilization, maternal race and mode of delivery. In particular, when maternal and child records are linked, this study suggests that when adjusted for maternal characteristics, the cost of vaginal deliveries followed by NICU utilization may be higher than the cost of Cesarean sections and NICU utilization.

ObjectiveCesarean section, one of the most frequently performed surgical procedures on women, is rising globally and in the USA. Much of the current Cesarean section literature focuses on reporting geographic and hospital-specific variations, but little has been published about the clinical and demographic characteristics of the patients, and even less about the economic consequences of a Cesarean section delivery compared with a vaginal delivery [e.g. the total hospital charges and length of neonatal intensive care unit-NICU stay] of a birth episode. To examine these relationships further, three urban Baltimore hospitals volunteered in 2004 to participate in a retrospective chart review that linked mother and child hospital records.

Methods1172 mother–child records were randomly selected and data regarding maternal co-morbidities, age, infant weight along with transfer to neonatal intensive care units, and economic data were extracted from the mother and child charts.

ConclusionAverage total charges for vaginal deliveries [maternal plus total baby charges that includes NICU utilization (X  $17 624.38)] may be higher than average total chargesfor Cesarean sections [maternal plus total baby charges that includes NICU utilization (X  $13 805.47)]. Specifically, maternal race – being African American – was indirectly associated with overall charges through its association with mode of delivery and NICU utilization patterns. The presence of maternal co-morbidities – Herpes Simplex Virus, hypertension and diabetes – most probably influenced babies’ hospital stay charges as well as NICU charges when transferred to NICU following both vaginal and Cesarean section deliveries. Thus, prenatal care targeting co-morbidities management may reduce the odds of a newborn’s transfer to NICU thus avoiding greater lengths of stay, medical care and charges. Recommendations for obstetrical practices as well as health care policy on their charges should not assume that Cesarean section deliveries are always costlier than vaginal deliveries.

Abstract:
As many as one-third of women suffer damage to the anterior part of the anal
sphincter at the time of their first vaginal delivery, and perhaps a third of
these have new bowel symptoms. This is one of the most common causes of fecal
incontinence. This study examined the long-term outcome in 55 consecutive women
who were followed for at least 5 years and for a median of 6.5 years after
anterior overlapping anal sphincter repair. Thirty-two of them underwent repair
shortly after delivery, and the other 23 underwent repair in middle age. Seven
of the 46 evaluable patients (15 percent) had required additional surgery for
fecal incontinence, and there was one outright failure. Of the remaining 38
patients, 27 (71 percent) reported improved bowel control, 23 of them by at
least 50 percent when rating their symptoms on a scale of 0 to 10. Five others
had not improved, and six reported that their condition had deteriorated. None
of the patients were fully continent when last evaluated, but six had no fecal
urgency, and eight were free of soiling. Twenty-five of the 38 patients found that
their symptoms restricted their lifestyle to some extent. Patient self-ratings
of improvement a median of 15 months after surgery predicted long-term outcome.

These findings suggest that the results of overlapping anal sphincter repair
performed in women with obstetric damage deteriorate over time. Patients should
know preoperatively that although they are likely to improve to some degree,
perfect continence is rare and new evacuation problems are a possibility. Many
of these patients will be satisfied by even slight improvement in their
symptoms.

Lancet 2000;355:260-265

Taking The Shame Out Of Pudendal Neuralgia

What could possibly be worse
than struggling with a painful condition and feeling ashamed to discuss the
problem because of its intimate nature? Such is the case for many suffering
with pudendal neuralgia, a little known disease that affects one of the most
sensitive areas of the body. This area is innervated by the pudendal nerve,
named after the Latin word for shame.
Due to the location of the discomfort combined with inadequate knowledge, some
physicians make reference to the pain as psychological. But nothing could be
further from the truth. Unfortunately, discussing the condition with
gynecologists, urologists and neurologists often proves fruitless since most
know nothing about the condition and therefore cannot diagnose it.

What is Pudendal Neuralgia?

Pudendal neuralgia is a chronic and painful condition that occurs in both men
and women, although studies reveal that about two-thirds of those with the
disease are women. The primary symptom is pain in the genitals or the
anal-rectal area and the immense discomfort is usually worse when sitting. The
pain tends to move around in the pelvic area and can occur on one or both sides
of the body. Sufferers describe the pain as burning, knife-like or aching,
stabbing, pinching, twisting and even numbness.
These symptoms are usually accompanied by urinary problems, bowel problems and
sexual dysfunction. Because the pudendal nerve is responsible for sexual
pleasure and is one of the primary nerves related to orgasm, sexual activity is
extremely painful, if not impossible for many pudendalites. When this nerve
becomes damaged, irritated, or entrapped, and pudendal neuralgia sets in, life
loses most of its pleasure.

Where is the pudendal nerve?

It lies deep in the pelvis and follows a path that comes from the sacral area
and later separates into three branches, one going to the anal-rectal area, one
to the perineum, and one to the penis or clitoris. Since there are slight
anatomic variations with each person, a patient's symptoms can depend on which
of the branches are affected, although often all three branches are involved.
The fact that the pudendal nerve carries sensory, motor, and autonomic signals
adds to the variety of symptoms that can be exhibited.

Pudendal Neuralgia and Depression

One of the most common symptoms that accompanies pudendal neuralgia is severe
depression. Some people with the disease have committed suicide due to the
intractable pain. For that reason, it is important to consider antidepressants,
as they can help lessen the hypersensitivity of the genital area in addition to
relieving bladder problems. Certain anti-seizure drugs reportedly help to
alleviate neuropathic pain while anti-anxiety drugs provide substantial relief
of muscle spasms and assist with sleeping.
Uninformed physicians are reluctant to prescribe opiates for an illness that
shows no visible abnormality, yet the desperate nature of genital nerve pain
requires that opiates be prescribed for these patients. While medications are
not always satisfactory, they do help take the edge off of the pain for many
people. Until the correct treatment is determined, it is imperative that
patients with pudendal neuralgia receive adequate pain management since the
pain associated with this illness can be intense.

Treatment

Treatment depends on the cause of distress to the nerve. When the cause is not
obvious patients are advised to try the least invasive and least risky
therapies initially.

-- Physical therapy that includes myofascial release and trigger point
therapy internally through the vagina or rectum assists with relaxing of the
pelvic floor, especially if pelvic floor dysfunction is the cause of nerve
irritation. If no improvement is found after six to twelve sessions, nerve
damage or nerve entrapment might be considered.

-- Botox is now used in medical settings to relax muscles and shows
promise when injected into pelvic floor muscles; though finding a physician
adept at this treatment is difficult.

-- Pudendal nerve blocks using a long-acting analgesic and a steroid can
reduce the nerve inflammation and are usually given in a series of three
injections four to six weeks apart.

There are three published approaches to pudendal nerve decompression surgery
but there is debate among members of the pudendal nerve entrapment community as
to which approach is the best. Since there are advantages and disadvantages to
each approach, patients face considerable confusion when deciding which type of
surgery to choose. Because there are only a handful of surgeons in the world
who perform these surgeries, most patients have to travel long distances for
help. Moreover, the recovery period is often painful and takes anywhere from
six months to several years since nerves heal very slowly. Unfortunately, early
statistics indicate that only 60 to 80 percent of surgeries are successful in
offering at least a 50 percent improvement. Patients whose surgeries are not
successful or who do not wish to pursue surgery have the option of trying an
intrathecal pain pump which delivers pain medication locally and helps to avoid
some of the side effects of oral medications. Others pursue the option of a neurostimulator
either to the sacral area or directly to the pudendal nerves. These are
relatively new therapies for pudendal neuralgia so it is difficult to predict
success rates. Some pudendalites have devised ingenious contraptions for pain
relief ranging from u-shaped cushions cut from garden pads all the way to
balloons filled with water, frozen, and inserted into the vagina. Most have a
favorite cushion for sitting and many have special computer set-ups for home
and office use in order to avoid sitting. Generally speaking, jeans are a
no-no, so patients revise their wardrobes to include baggy pants and baggy
underwear - if they are able to tolerate wearing underwear.
Clearly more research is required to find effective methods to better manage
the pain and debilitation of pudendal neuralgia. But in the meantime, friends
and family close to those who have this devastating illness play a huge role in
helping patients cope, thereby maintaining the best quality of life possible.
Support, love and understanding are of primary importance for those suffering
with this affliction.

Written by: Ms. Violet Matthews

Ms. Violet Matthews has a Bachelor's degree in nursing and has been an active
member of a Pudendal Neuralgia forum for 2years. Having suffered with Pudendal Neuralgia, she has seen a 75%
improvement in quality of life since her pudendal nerve decompression surgery
in France
two years ago. Married with two children, Ms. Matthews resides in Southwestern United States. You can usually find Violet
at pudendal.info/phpBB2

Abstract:
Objective: The purpose of this study was to determine the increase in pudendal
nerve branch lengths using a 3D computer model of vaginal delivery.

Study design: The main inferior rectal and perineal branches of the pudendal
nerve were dissected in 12 hemi-pelves from 6 adult female cadavers. Their 3D
courses were digitized in the 4 specimens with the most characteristic nerve
branching pattern, and the data were imported into a published 3D computer
model of the pelvic floor. Each nerve branch was then represented by a
stretchable cord with a fixation point at the ischial spine. The length change in
each branch was then quantified as the fetal head descended through the pelvic
floor. The maximum nerve strains ([final length minus original length/original
length] x 100) were calculated for 5 degrees of perineal descent: reference
descent from the literature, 1.25 cm and 2.5 cm caudal and cephalad. The effect
of alternative fixation points on resultant nerve strain was also studied.

Results: The inferior rectal branch exhibited the maximum strain, 35%, and
this strain varied by 15% from the scenario with the least perineal descent to
that with the most perineal descent. The strain in the perineal nerve branch
innervating the anal sphincter reached 33%, while the branches innervating the
posterior labia and urethral sphincter reached values of 15% and 13%,
respectively. The more proximal the nerve fixation point, the greater the nerve
strain.

Conclusion: During the second stage: (1) nerves innervating the anal
sphincter are stretched beyond the 15% strain threshold known to cause
permanent damage in appendicular peripheral nerve, and (2) the degree of
perineal descent is shown to influence pudendal nerve strain.

MethodologyA population of 100 children aged 4–15
years and diagnosed with developmental delay syndrome(s) were investigated
using a parental questionnaire to determine whether they had suffered any birth
interventions or distress. These results were compared with an age- and
gender-matched control group.

ResultsOn the basis of this relatively small
study, significant risk of development delay syndrome(s) occurred with both
foetal distress (p < 0.001) and Ventouse assisted delivery
(p < 0.01).

-------------------------------------------------------------------

Health visitors are now the health police - and the
government's campaign to stop aggression against NHS staff is backfiring, says
maternity pressure group

The witch hunt for potentially abusive parents is now dominating and
distorting supportive services for parents, says maternity pressure group.

Health visitors, who used to take over where maternity care left off, are
now visiting women if possible before the baby comes, and their first job is to
question mothers to assess them to see how great a risk they may be to their
babies. They are doing this secretly, without consent, and without telling mothers
the real reason; they will say that it is to see if they will need extra help.
What it usually meant is extra surveillance - and a risk-rating which will stay
for ever on the child's and mother's record. They ask questions about past
episodes of mental illness, how she got on with her own mother, domestic
violence, and so on. This means that any subsequent accident or illness in the
child may be seen as suspicious in mothers who get a high rating.

"This fits in with the whole pattern we are now seeing in child
care" says Beverley Beech, Chair of AIMS, "Surveillance and
suspecting parents - mostly mothers - has taken over from support which many
first-time mothers need."

"The fact that health visitors have given in so easily to this, and are
carrying out this secret surveillance makes us question what has happened to
the ethics of the nursing profession."

Research has shown that the vast majority of parents labelled as high risk
by this system will never abuse their children - and some parents labelled as
low risk will.

There are parents who need more support, but all our evidence suggests that
the real practical support isolated parents need is not there. Increasingly,
health visitors simply report anyone with problems to social services - who
also increasingly get care orders rather than providing real support. "And
real support is what parents find supportive - not simply what a social worker
thinks they should have. Increasingly we find what gets good marks from health
visitors and social workers is passive compliance. But for someone coping as a
single parent, or in difficult circumstances, a passive compliant parent may
not be the best protection for children".

Parents are not obliged to use health visitors. They are entitled to refuse.
But some parents who exercised their right to refuse were reported to social
services as a potential risk to their children. "The whole of child care
is becoming much more authoritarian in approach - and the sad result is that
professionals are much less trusted." say Beverley Beech, and Jean
Robinson, AIMS Hon. Research Officer.

Recent research has shown that mothers lie when they are asked questions
about postnatal depression: they are afraid to tell the truth in case they are
reported to social services and their babies are taken. So they are not getting
help. (research details available from AIMS)